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far, the safest, most reliable/reproducible approach to complex valve
surgery is using conventional techniques...
As I discussed in the section on coronary artery bypass surgery, the
median sternotomy incision provides the best exposure to all regions of
the heart and great vessels. It's easy to perform and it's
remarkably well-tolerated.
Let me take a moment to discuss two concerns about having a sternal
splitting operation. The first is the concern about having pain.
The second is the concern about a delay in return to normal activities.
Unfortunately, the sternal incision has been given a bad rap.
People often refer to it as "cracking the chest." Even many heart
surgeons are critical of the sternal incision, particularly those who
are promoting less invasive surgery.
The fact is, the sternal incision has served us well for decades and
continues to be the incision of choice for most open heart procedures.
Here's a picture of my Mom only 4 weeks after conventional
aortic valve replacement and two-vessel coronary artery bypass surgery!
By the way, my Mom was 78 years old in this picture and is now 87 and
doing fine. She never had one day of pain from her sternal
incision. In fact, there were only two incisions that bothered
her. The first was the puncture site for the cardiac
catheterization which was black and blue for months. The second
was the incision in her arm where the surgeon harvested the radial
artery for one of the bypass grafts. She still complains that her
hand is always cold. But no pain from her sternal incision.
Let me explain... First, when we make a sternal incision we cut
through little to no muscle. If you feel your chest in the
midline, there's nothing by skin and bone. The large pectoralis
muscles are on either side of the midline. There are no major
nerves in the midline either. Your nerves come from your spine and
end in the midline. Ironically, most of the "less invasive"
procedure utilize an incision between the ribs. There's a nerve
under each rib (the "intercostal nerve") which is quite painful once
disturbed. Have you ever heard of the pain associated with a
broken rib? It's bad.
So, what about splitting the sternal bone? Doesn't that hurt?
First, you have to understand that we reconstruct the bone with
stainless steel wires or cables as shown below.
And, like any "broken bone" once it's "fixed" it usually doesn't hurt
too badly. I'm always impressed how little discomfort patients
have after a conventional sternotomy.
Recently, I performed mitral valve repairs in two young men, both 48
years old, on the same day using the conventional sternotomy approach.
On post-operative day 1, they described their pain as "4 out of 10"
mostly from the chest drains. On day 2 (with the drains removed),
their pain was "2 out of 10." They both were discharged to home on
day 3 and when they returned to the office in follow-up two weeks later,
both described having absolutely no pain or discomfort whatsoever.
You can see the typical look of the incision on post-operative day 3
and what it looks like after it's healed completely. Not as brutal
as some suggest.
Here are pictures of the sternotomy wound in a 50 year old woman
approximately 4 weeks after surgery. You can see in this first
picture that even with a low cut shirt, there is minimally scar
noticeable.
Even with her shirt pulled away, I think you can see that the sternotomy
scar will go on to heal nicely and be more hidden than you might have
expected.
After a sternotomy, you will be awake and alert after your operation
and removed from the ventilator within an hour or two later. The
first evening of your surgery you'll be sitting in a chair. By day
2 you'll be walking in the halls and by day 3 you'll be walking stairs
and looking toward going home.
At home, you'll be able to continue to walk stairs and gradually
resume normal activities. We recommend not driving a car for 4
weeks and not lifting over 20 pounds for two months.
Which gets us to the final issue... When can I go back to work?
There is no doubt that after a sternotomy, you shouldn't lift
anything heaving for 2-3 months. So, if you're in construction or
if you're required to lift heavy objects at work, you may not be able to
resume full duties for 3 months. Of course, most of our patients
aren't required to do that much lifting and many of my patients return
to work in 6 weeks --which is little different than my patients
who have "less-invasive" techniques.
Nevertheless, the debate over sternotomy versus the less invasive
techniques continues. Again, I'm not someone who has stuck his
head in the sand. I began performing less invasive heart
procedures in 1997. A lot of patients prefer the less invasive
approach and we've enjoyed a lot of success with less invasive
techniques. It's just not completely clear to me that it's better
than conventional techniques. Sadly, a lot of surgeons perform
less invasive techniques more for marketing purposes rather than truly
believing they are doing a better operation. I discussed this in
my editorial on President Clinton's heart surgery.
Nevertheless, we continue to use less invasive techniques in select
patients and we're adding new procedures every year. No doubt,
there are increasing numbers of patients who are requesting less invasive approaches.
And, in select cases the less invasive approach has certain advantages. I discuss
this extensively on the "Less Invasive" page.
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